2016 LOUISIANA RESIDENT - 2D Name Change Taxpayer SSN

IT-540-2D (Page 1 of 4) DEV ID 2016 LOUISIANA RESIDENT - 2D Name Change Taxpayer SSN

Decedent Filing Spouse SSN

Spouse Decedent

Address Change Telephone

Amended Return Taxpayer DOB Spouse DOB NOL Carryback

FILING STATUS: Enter the appropriate number in the filing status box. It must agree with your federal return. 6 EXEMPTIONS: 65 or Qualifying 6A Yourself Blind Enter a “1” in box if single. X older Widow(er) Total of Enter a “2” in box if married filing jointly. 6A & 6B 65 or 6B Spouse Blind Enter a “3” in box if married filing separately. older Enter a “4” in box if head of household. If the qualifying person is not your dependent, enter name here. Enter a “5” in box if qualifying widow(er).

6C DEPENDENTS – Enter dependent information below. If you have more than 6 dependents, attach a statement to your return with the required information. Enter the total number from Federal Form 1040A, Line 6c, or Federal Form 1040, Line 6c. 6C

Dependent First and Last Name Social Security Number Relationship to you Birth Date (mm/dd/yyyy)

IMPORTANT! All four (4) pages of this return MUST be mailed 6D TOTAL EXEMPTIONS – Total of 6A, 6B, and 6C 6D in together along with your W-2s and completed schedules. Please paperclip. Do not staple.

FOR OFFICE USE ONLY Field Flag 61731 IT-540-2D (Page 2 of 4) Social Security Number

If you are not required to file a federal return, indicate wages here. Mark this box and enter zero “0” on Lines 7 through 14.

From Louisiana FEDERAL ADJUSTED GROSS INCOME – If your Federal Adjusted 7 Schedule E, 7 ”. Gross Income is less than zero, enter “0 attached

8A FEDERAL ITEMIZED DEDUCTIONS 8A

8B FEDERAL STANDARD DEDUCTION 8B

8C EXCESS FEDERAL ITEMIZED DEDUCTIONS – Subtract Line 8B from Line 8A. 8C

FEDERAL INCOME TAX – If your federal income tax has been decreased by a federal 9 disaster credit allowed by IRS, complete Schedule H and mark the box. 9

YOUR LOUISIANA TAX TABLE INCOME – Subtract Lines 8C and 9 from Line 7. If less than zero, 10 enter “0”. 10

11 YOUR LOUISIANA INCOME TAX 11

12 EDUCATION CREDIT Number of qualifying dependents 12

13 OTHER NONREFUNDABLE PRIORITY 1 CREDITS – From Schedule C, Line 9 13

TAX LIABILITY AFTER NONREFUNDABLE PRIORITY 1 CREDITS – Subtract Lines 12 and 13 from 14 14 Line 11.

15 2016 LOUISIANA REFUNDABLE CHILD CARE CREDIT 15

15A Enter the qualified expense amount from the Refundable Child Care Credit Worksheet, Line 3. 15A

15B Enter the amount from the Refundable Child Care Credit Worksheet, Line 6. 15B

16 2016 LOUISIANA REFUNDABLE SCHOOL READINESS CREDIT 16 5 4 3 2

17 EARNED INCOME CREDIT – From Louisiana Earned Income Credit (LA EIC) Worksheet, Line 3. 17

18 LOUISIANA CITIZENS INSURANCE CREDIT 18A 18

19 OTHER REFUNDABLE PRIORITY 2 CREDITS – From Schedule F, Line 10 19

TOTAL REFUNDABLE PRIORITY 2 CREDITS – Add Lines 15 and 16 through 19. Do not include 20 20 amounts on Lines 15A, 15B, and 18A.

21 TAX LIABILITY AFTER REFUNDABLE PRIORITY 2 CREDITS 21

22 OVERPAYMENT AFTER REFUNDABLE PRIORITY 2 CREDITS 22

23 NONREFUNDABLE PRIORITY 3 CREDITS – From Schedule J, Line 16 23

61732 IT-540-2D (Page 3 of 4) Social Security Number

ADJUSTED LOUISIANA INCOME TAX – Subtract Line 23 from Line 21. If the result is less than zero or you 24 are not required to file a federal return, enter zero “0”. 24

25A CONSUMER USE TAX for purchases before April 1, 2016 No use tax due. 25A

Amount from the Consumer Use 25B CONSUMER USE TAX for purchases on or after April 1, 2016 Tax Worksheet. 25B

26 TOTAL INCOME TAX AND CONSUMER USE TAX – Add Lines 24, 25A, and 25B. 26

27 OVERPAYMENT AFTER REFUNDABLE PRIORITY 2 CREDITS – Enter the amount from Line 22. 27

28 REFUNDABLE PRIORITY 4 CREDITS – From Schedule I, Line 6 28

29 AMOUNT OF LOUISIANA TAX WITHHELD FOR 2016 – Attach Forms W-2 and 1099. 29

30 AMOUNT OF CREDIT CARRIED FORWARD FROM 2015 30

31 AMOUNT OF ESTIMATED PAYMENTS MADE FOR 2016 31

32 AMOUNT PAID WITH EXTENSION REQUEST 32

33 TOTAL REFUNDABLE TAX CREDITS AND PAYMENTS – Add Lines 27 through 32. 33

OVERPAYMENT – If Line 33 is greater than Line 26, subtract Line 26 from Line 33. Otherwise, 34 enter zero “0” on Lines 34 through 40 and go to Line 41. 34

35 UNDERPAYMENT PENALTY – If you are a farmer, mark the box. 35

ADJUSTED OVERPAYMENT – If Line 34 is greater than Line 35, subtract Line 35 from Line 34 and 36 enter the result here. If Line 35 is greater than Line 34, enter zero “0” on Lines 36 through 40, subtract 36 Line 34 from Line 35, and enter the balance on Line 41.

37 TOTAL DONATIONS – From Schedule D, Line 24 37

REFUND DUE 38 SUBTOTAL – Subtract Line 37 from Line 36. This amount of overpayment is available for credit or refund. 38

39 AMOUNT OF LINE 38 TO BE CREDITED TO 2017 INCOME TAX CREDIT 39

AMOUNT TO BE REFUNDED – Subtract Line 39 from Line 38. 40 Enter a “2” in box if you want to receive your refund by paper check. 40 Enter a “3” in box if you want to receive your refund by direct deposit and complete the information below. If the information is unreadable, you will receive your refund REFUND by paper check. If you are filing for the first time or if you do not make a refund selection, you will receive your refund by paper check. DIRECT DEPOSIT INFORMATION Will this refund be forwarded to a financial Type: Checking Savings institution located outside the United States? Yes No

Routing Account Number Number

61733 IT-540-2D (Page 4 of 4) Social Security Number

AMOUNTS DUE LOUISIANA

AMOUNT YOU OWE – If Line 26 is greater than Line 33, subtract Line 33 from Line 26 and enter the balance 41 41 here.

42 ADDITIONAL DONATION TO THE MILITARY FAMILY ASSISTANCE FUND 42

43 ADDITIONAL DONATION TO THE COASTAL PROTECTION AND RESTORATION FUND 43

44 ADDITIONAL DONATION TO LOUISIANA FOOD BANK ASSOCIATION 44

45 INTEREST 45

46 DELINQUENT FILING PENALTY 46

47 DELINQUENT PAYMENT PENALTY 47

48 UNDERPAYMENT PENALTY – If you are a farmer, mark the box. 48

49 BALANCE DUE LOUISIANA – Add Lines 41 through 48. PAY THIS AMOUNT. 49 DO NOT SEND CASH.

IMPORTANT! All four (4) pages of this return MUST be mailed in together along with your W-2s and completed schedules. Please paperclip. Do not staple.

2-D Barcode Area Status

Contribution and Donation

I declare that I have examined this return, and to the best of my knowledge, it is true and complete. Declaration of paid preparer is based on all available information. If I made a contribution to the START Savings Program, I consent that my Social Security Number may be given to the Louisiana Office of Student Financial Assistance to properly identify the START Savings Program account holder. If married filing jointly, both Social Security Numbers may be submitted. I understand that by submitting this form I authorize the disburse- ment of individual income tax refunds through the method as described on Line 40.

Your Signature Date Signature of paid preparer other than taxpayer

Spouse’s Signature (If filing jointly, both must sign.) Date Telephone number of paid preparer Date

Name Address

Social Security Number, PTIN, or FEIN of paid preparer Individual Income Tax Return Calendar year return due 5/15/2017 Mail to: Department of Revenue SPEC CODE

61734 Social Security Number

SCHEDULE C – 2016 NONREFUNDABLE PRIORITY 1 CREDITS

CREDIT FOR TAX LIABILITIES PAID TO OTHER STATES – A copy of the return filed with the other states must be 1 submitted with this schedule.

1A Enter the total of Net Tax Liability Paid to Other States from Form R-10606. 1A

1B Enter the Credit for Taxes Paid to Other States from Form R-10606. 1B

2 CREDIT FOR CERTAIN DISABILITIES - Mark an “X” in the appropriate boxes. Only one credit is allowed per person.

Loss of Mentally Deaf Blind Limb Incapacitated Enter the total number of qualifying 2D individuals. Only one credit is allowed 2D 2A Yourself per person.

2B Spouse 2E Multiply Line 2D by $72. 2E 2C Dependent * * List dependent names here. 

3 CREDIT FOR CONTRIBUTIONS TO EDUCATIONAL INSTITUTIONS 3A 3A Enter the value of computer or other technological equipment donated. Attach Form R-3400.

3B 3B Multiply Line 3A by 29 percent. Round to the nearest dollar.

4 CREDIT FOR CERTAIN FEDERAL TAX CREDITS 4A 4A Enter the amount of eligible federal credits.

4B 4B Multiply Line 4A by 7.2 percent. Enter the result or $18, whichever is less. This credit is limited to $18.

Additional Nonrefundable Priority 1 Credits Enter credit description and associated code, along with the dollar amount of credit claimed. Credit Description Credit Code Amount of Credit Claimed

5 5

6 6

7 7

8 8

TOTAL NONREFUNDABLE PRIORITY 1 CREDITS – Add Lines 1B, 2E, 3B, 4B, and 5 9 through 8. Enter the result here and on Form IT-540-2D, Line 13. 9

61735 Social Security Number

SCHEDULE D – 2016 DONATION SCHEDULE Individuals who file an individual income tax return and have overpaid their tax may choose to donate all or part of their overpayment shown on Line 36 of Form IT-540-2D to the organizations or funds listed below. Enter on Lines 2 through 23, the portion of the overpayment you wish to donate. The total on Line 24 cannot exceed the amount of your overpayment on Line 36 of Form IT-540-2D.

1 Adjusted Overpayment - From IT-540-2D, Line 36 1

DONATIONS OF LINE 1

The Military Family Assistance The Louisiana Youth Leadership 2 2 13 13 Fund Seminar Corporation

Coastal Protection and Lighthouse for the Blind in New 3 3 14 14 Restoration Fund Orleans

The Louisiana Association for 4 The START Program 4 15 15 the Blind

Wildlife Habitat and Natural Heritage 5 Trust Fund 5 16 Louisiana Center for the Blind 16

6 Louisiana Cancer Trust Fund 6 17 Affiliated Blind of Louisiana, Inc. 17

Louisiana Animal Welfare Louisiana State Troopers 7 7 18 18 Commission Charities, Inc.

8 Louisiana Food Bank Association 8 19 Friends of Palmeto State Park 19

Make-A-Wish Foundation of the 9 9 20 The American Rose Society 20 Texas Gulf Coast and Louisiana

Louisiana Association of United 10 10 21 The Extra Mile 21 Ways/LA 2-1-1

Louisiana Naval War Memorial 11 American Red Cross 11 22 Commission; U.S.S. KIDD 22

Louisiana National Guard Honor Children’s Therapeutic Services 12 12 23 23 Guard for Military Funerals at the Emerge Center

TOTAL DONATIONS – Add Lines 2 through 23. This amount cannot be more than Line 1. Also, enter this 24 24 amount on Form IT-540-2D, Line 37.

61736 SCHEDULE E – 2016 ADJUSTMENTS TO INCOME Social Security Number

FEDERAL ADJUSTED GROSS INCOME – Enter the amount from your Federal Form 1040EZ, Line 4, 1 1 OR Federal Form 1040A, Line 21, OR Federal Form 1040, Line 37. Mark box if amount is less than zero.

INTEREST AND DIVIDEND INCOME FROM OTHER STATES AND THEIR POLITICAL 2 2 SUBDIVISIONS

2A RECAPTURE OF START CONTRIBUTIONS 2A

3 TOTAL – Add Lines 1, 2, and 2A. 3

EXEMPT INCOME – Enter on Lines 4A through 4H the amount of exempted income included in Line 1 above. Enter description and associated code, along with the dollar amount. Exempt Income Description Code Amount

4A 4A

4B 4B

4C 4C

4D 4D

4E 4E

4F 4F

4G 4G

4H 4H

4I EXEMPT INCOME BEFORE APPLICABLE FEDERAL TAX – Add Lines 4A through 4H. 4I

4J FEDERAL TAX APPLICABLE TO EXEMPT INCOME 4J

4K EXEMPT INCOME – Subtract Line 4J from Line 4I. 4K

LOUISIANA ADJUSTED GROSS INCOME BEFORE IRC 280C EXPENSE ADJUSTMENT – 5A Subtract Line 4K from Line 3. 5A

5B IRC 280C EXPENSE ADJUSTMENT 5B

LOUISIANA ADJUSTED GROSS INCOME – Subtract Line 5B from Line 5A. Enter the result here 5C 5C and on Form IT-540-2D, Line 7.

Description Code Description Code Interest and Dividends on US Government Obligations...... 01E Native American Income ...... 08E Louisiana State Employees’ Retirement Benefits (Date Retired)...... 02E START Savings Program Contribution...... 09E Taxpayer Spouse Military Pay Exclusion...... 10E Road Home ...... 11E Louisiana State Teachers’ Retirement Benefits (Date Retired)...... 03E Recreation Volunteer ...... 13E Taxpayer Spouse Volunteer Firefighter ...... 14E Federal Retirement Benefits (Date Retired)...... 04E Voluntary Retrofit Residential Structure...... 16E Taxpayer Spouse Elementary and Secondary School Tuition...... 17E Other Retirement Benefits (Date Retired)...... 05E Educational Expenses for Home-Schooled Children...... 18E Provide name or statute: Educational Expenses for Quality Public Education...... 19E Taxpayer Spouse Capital Gain from Sale of Louisiana Business...... 20E Annual Retirement Income Exemption for Taxpayers 65 or over ...... 06E Employment of Certain Qualified Disabled Individuals...... 21E Provide name of pension or annuity: Other 49E Taxable Amount of Social Security...... 07E Identify:

61737 Social Security Number

SCHEDULE F – 2016 REFUNDABLE PRIORITY 2 CREDITS

1 Credit for amounts paid by certain military service members for obtaining Louisiana Hunting and Fishing Licenses.

1A Yourself Date of Birth (MM/DD/YYYY) ______Driver’s License number ______State of issue ______or State Identification ______State of issue ______1B Spouse Date of Birth (MM/DD/YYYY) ______Driver’s License number ______State of issue ______or State Identification ______State of issue ______

1C Dependents: List dependent names. Dependent name ______Date of Birth (MM/DD/YYYY) ______Dependent name ______Date of Birth (MM/DD/YYYY) ______Dependent name ______Date of Birth (MM/DD/YYYY) ______Dependent name ______Date of Birth (MM/DD/YYYY) ______

1D Enter the amount of the credit for fees paid by certain military service members for obtaining Louisiana Hunting and Fishing Licenses. 1D Additional Refundable Priority 2 Credits Enter credit description and associated code, along with the dollar amount of credit claimed. Credit Description Credit Code Amount of Credit Claimed

2 2

3 3

4 4

5 5

6 6

Transferable, Refundable Priority 2 Credits Enter the State Certification Number from Form R-6135, along with the dollar amount of credit claimed.

Credit Description Credit Code Amount of Credit Claimed

7. Musical and Theatrical Production 62F 7 . 7A

8. Musical and Theatrical Production 62F 8

8A.

9. Musical and Theatrical Production 62F 9

9A.

10. OTHER REFUNDABLE PRIORITY 2 CREDITS – Add Lines 1D and 2 through 9. Enter the result 10 here and on Form IT-540-2D, Line 19.

61738 Social Security Number

*** Schedule G omitted on purpose ***

SCHEDULE H – 2016 MODIFIED FEDERAL INCOME TAX DEDUCTION

Enter the amount of your federal income tax liability as shown on the Federal Income Tax 1 1 Deduction Worksheet.

2 Enter the amount of federal disaster credits allowed by IRS. 2

3 Add Line 1 and Line 2. Enter the result here and on Form IT-540-2D, Line 9. 3

SCHEDULE I – 2016 REFUNDABLE PRIORITY 4 CREDITS Enter credit description and associated code, along with the dollar amount of credit amount claimed. Credit Description Credit Code Amount of Credit Claimed

1 1

2 2

3 3

4 4

5 5

TOTAL REFUNDABLE PRIORITY 4 CREDITS – Add Lines 1 through 5. Enter the result here and 6 6 on Form IT-540-2D, Line 28.

{SCH f} 61739 Social Security Number

SCHEDULE J – 2016 NONREFUNDABLE PRIORITY 3 CREDITS Nonrefundable Child Care Credits

1 FEDERAL CHILD CARE CREDIT 1

2 2016 LOUISIANA NONREFUNDABLE CHILD CARE CREDIT 2

3 AMOUNT OF LOUISIANA NONREFUNDABLE CHILD CARE CREDIT CARRIED FORWARD FROM 2012 THROUGH 2015 3

4 2016 LOUISIANA NONREFUNDABLE SCHOOL READINESS CREDIT 4 5 4 3 2

AMOUNT OF LOUISIANA NONREFUNDABLE SCHOOL READINESS CREDIT CARRIED FORWARD FROM 2012 THROUGH 5 5 2015

Additional Nonrefundable Priority 3 Credits Enter credit description and associated code, along with the dollar amount of credit claimed. Credit Description Credit Code Amount of Credit Claimed

6 6

7 7

8 8

9 9

10 10

11 11

61740 Social Security Number

SCHEDULE J – 2016 NONREFUNDABLE PRIORITY 3 CREDITS ...continued Transferable, Nonrefundable Priority 3 Credits Enter credit description and associated code, along with the dollar amount of credit claimed and the State Certification Number from Form R-6135.

Credit Description Credit Code Amount of Credit Claimed

12 12

12A

13 13

13A

14 14

14A

15 15

15A

TOTAL NONREFUNDABLE PRIORITY 3 CREDITS – Add Lines 2 through 15. Also, enter 16 this amount on Form 540-2D, Line 23. 16

61741 2016 Louisiana School Expense Deduction Worksheet (For use with Form IT-540-2D)

Your Name Your Social Security Number

I. This worksheet should be used to calculate the three School Expense Deductions listed below. Refer to Revenue Information Bulletin 12-008 and 09-019 on LDR’s website. 1. Elementary and Secondary School Tuition – R.S. 47:297.10 provides a deduction for amounts paid during the tax year for tuition and fees required for your dependent child’s enrollment in a nonpublic elementary or secondary school that complies with the criteria set forth in Brumfield v. Dodd and Section 501(c)(3) of the Internal Revenue Code or to any public elementary or secondary laboratory school that is operated by a public college or university. The school can verify that it complies with the criteria. The deduction is equal to the actual amount of tuition and fees paid per dependent, limited to $5,000. The tuition and fees that can be deducted include amounts paid for tuition, fees, uniforms, textbooks and other supplies required by the school. 2. Educational Expenses for Home-Schooled Children – R.S. 47:297.11 provides a deduction for educational expenses paid during the tax year for home-schooling your dependent child. In order to qualify for the deduction, you must be approved by the State Board of Elementary and Secondary Education (BESE) for home-schooling. The deduction is equal to 50 percent of the actual qualified educational expenses paid for the home-schooling per dependent, limited to $5,000. Qualified educational expenses include amounts paid for the purchase of textbooks and curricula necessary for home-schooling. 3. Educational Expenses for a Quality Public Education – R.S. 47:297.12 provides a deduction for the fees or other amounts paid during the tax year for a quality education of a dependent child enrolled in a public elementary or secondary school, including Louisiana Department of Education approved charter schools. The deduction is equal to 50 percent of the amounts paid per dependent, limited to $5,000. The amounts that can be deducted include amounts paid for uniforms, textbooks and other supplies required by the school. II. On the chart below, list the name of each qualifying dependent and the name of the school the student attends. If the student is home-schooled, enter “home-schooled.” Enter an “X” in the box in column 1 if your dependent qualifies for the Elementary and Secondary School Tuition deduction, column 2 for Educational Expenses for Home-Schooled Children deduction, or column 3 for Quality Public Education deduction. If you have more than six qualifying dependents, attach a statement to your return with the required information.

Deduction as described Student Name of Qualifying Dependent Name of School in Section I 1 2 3 A

III. Using the letters that correspond to each qualifying dependent listed in Section II, list the amount paid per student for each qualifying expense. For students attending a qualifying school, the expense must be for an item required by the school. Refer to the information in Section I to determine which expenses qualify for the deduction. Retain copies of cancelled checks, receipts and other documentation in order to support the amount of qualifying expenses. If you checked column 1 in Section II, skip the 50% calculation below; however, the deduction is still limited to $5,000.

List the amount paid for each student as listed in Section II. Qualifying Expense A B C D E F Tuition and Fees

School Uniforms

Textbooks, or Other Instructional Materials

Supplies

Total (add amounts in each column) If column 2 or 3 in Section II was checked, 50% 50% 50% 50% 50% 50% multiply by: Deduction per Student – Enter the result or $5,000 whichever is less.

IV. Total the Deduction per Student in Section III, based on the deduction for which the students qualified as marked in boxes 1,2, or 3 in Section II.

Enter the Elementary and Secondary School Tuition Deduction here and on IT-540-2D, Schedule E, code 17E. $ Enter the Educational Expenses for Home-Schooled Children Deduction here and on IT-540-2D, Schedule E, code 18E. $ Enter the Educational Expenses for a Quality Public Education Deduction here and on IT-540-2D, Schedule E, code 19E. $

61708 2016 Louisiana Refundable Child Care Credit Worksheet (For use with Form IT-540-2D) Your Name Social Security Number

Your Federal Adjusted Gross Income must be $25,000 or less in order to complete this form. 1. Care Provider Information Schedule – Complete columns A through D for each person or organization that provided care to your child. You may use Federal Form W-10, supplied by your provider, to obtain the information. If your care provider does not provide a Federal Form W-10, complete those parts of the Care Provider Information Schedule for which you have the information. You must follow the same rules of “Due Diligence” as the IRS requires if you do not have all of the care provider information. See IRS 2016 Publication 503 for information on “Due Diligence.” If additional lines are required for Lines 1 or 2, attach a schedule. Falsification of any information provided on this form constitutes fraud and can result in criminal penalties. Care Provider Information Schedule A B C D Address (number, street, apartment Identifying number Amount paid Care provider’s name number, city, state, and ZIP) (SSN or EIN) (See instructions.)

.00

.00 2. For each child under age 13, enter their name in column E, their Social Security Number in column F, and the amount of Qualified Expenses you incurred and paid in 2016 in column G. E F G Qualified expenses you Qualifying person’s name Qualifying person’s incurred and paid in 2016 for Social Security Number First Last the person listed in column (E)

.00

Add the amounts in column G, Line 2. Do not enter more than $3,000 for one qualifying person or 3 3 $6,000 for two or more persons. Enter this amount here and on Form IT-540-2D, Line 15A. .00 4 Enter your earned income. 4 .00 If married filing jointly, enter your spouse’s earned income (if your spouse was a student or was 5 5 disabled, see IRS Publication 503). All other filing statuses, enter the amount from Line 4. .00 6 Enter the smallest of Lines 3, 4, or 5. Enter this amount on Form IT-540-2D, Line 15B. 6 .00 7 Enter your Federal Adjusted Gross Income from Form IT-540-2D, Line 7, or Schedule E, Line 1, if filed. 7 .00 Enter on Line 8 the decimal amount shown below that applies to the amount on Line 7. If Line 7 is: over but not over decimal amount $0 $15,000 .35 8 $15,000 $17,000 .34 8 X . ______$17,000 $19,000 .33 $19,000 $21,000 .32 $21,000 $23,000 .31 $23,000 $25,000 .30 9 Multiply Line 6 by the decimal amount on Line 8. 9 .00 10 Multiply Line 9 by 50 percent and enter this amount on Line 11. 10 X .50 11 Enter this amount on Form IT-540-2D, Line 15. 11 .00

61713 2016 Louisiana Refundable School Readiness Credit Worksheet (For use with Form IT-540-2D) Your Name Social Security Number

R.S. 47:6104 provides a School Readiness Credit in addition to the credit for child care expenses as provided under R.S. 47:297.4. To qualify for this credit, the taxpayer must have Federal Adjusted Gross Income of $25,000 or less and must have incurred child care expenses for a qualified dependent under age six who attended a child care facility that is participating in the Quality Start Rating program administered by the Louisiana Department of Education. The qualifying child care facility must have provided the taxpayer with Form R-10614 which verifies the facility’s name, the state license number, the LA Revenue Account number, the Star Rating, and the rating award date. Complete this worksheet only if you claimed a Louisiana Refundable Child Care Credit on Form IT 540-2D, Line 15.

1. Enter the amount of 2016 Louisiana Refundable Child Care Credit on the Louisiana Refundable Child Care Credit Worksheet, Line 11 ...... 1 . 00 Using the Star Rating of the child care facility that your qualified dependent attended during 2016, shown on Form R-10614, determine the applicable percentage for the School Readiness Credit from the chart shown below:

A Quality Rating B Percentages for Star Rating Five Star 200% (2.0) Four Star 150% (1.5) Three Star 100% (1.0) Two Star 50% (.50) One Star 0% (.00)

2. Enter the number of your qualified dependentsunder age six who attended a:

Five Star Facility ______and multiply the number by 2.0 ...... (i) ______. ______

Four Star Facility ______and multiply the number by 1.5 ...... (ii) ______. ______

Three Star Facility ______and multiply the number by 1.0 ...... (iii) ______. ______

Two Star Facility ______and multiply the number by .50 ...... (iv) ______. ______

3 Add lines (i) through (iv) and enter the result. Be sure to include the decimal. 3 ______. ______

4 Multiply Line 1 by the total on Line 3. If the number results in a decimal, round to the nearest dollar and enter the result here and on Form IT-540-2D, Line 16...... 4 ______. 00

On Form IT-540-2D, Line 16, enter in the boxes designated for 5, 4, 3, or 2 the number of your qualified dependents as shown on Line 2 above for the associated star rated facility.

2016 Louisiana Earned Income Credit Worksheet

R.S. 47:297.8 allows a refundable credit for resident individuals who claimed and received a Federal Earned Income Credit (EIC). The Federal EIC is available for certain individuals who work, have a valid Social Security Number, and have a qualifying child, or are between ages 25 and 64. These individuals cannot be a qualifying child or dependent of another person.

Complete only if you claimed a Federal Earned Income Credit (EIC)

1 Federal Earned Income Credit – Enter the amount from Federal Form 1040EZ, Line 8a, OR Federal Form 1040A, Line 42a, OR Federal Form 1040, Line 66a...... 1 . 00

2 Multiply Line 1 above by 3.5 percent, round to the nearest dollar, and enter the result on Line 3...... 2 X .035

3 Enter this amount on Form IT-540-2D, Line 17...... 3 . 00

61714